The Meaning of Work


work employment recovery meaning occupation
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     Occupational therapy is founded on the belief that participation in meaningful activities is beneficial to health and well-being. Some of the health-promoting effects associated with participation in occupation-based mental health services and in meaningful activities include improved perspective on quality of life, a sense of well-being, improved confidence and self-esteem, decreased use of crisis services and hospitalizations, and improved socioeconomic status (Gewurtz & Hirsh, 2006). While occupational therapy encompasses far more than engagement in paid employment, participation in work and related activities is recognized as contributing to the well-being and recovery of individuals labeled with serious mental illness, while the absence of engagement in meaningful work is associated with decreased signs of health and well-being for this population. The following serves to illustrate the perspective of individuals labeled with serious mental illness on the meaning of work, highlights the health benefits associated with participation in work, and enhances understanding of how occupational therapists can support the recovery process through supporting employment goals.

     A meta-analysis of qualitative studies on the perspectives of individuals labeled with serious mental illness found that this population identified many benefits of being employed, including “greater autonomy, status and acceptance within society, structured use of time, a sense of purpose or focus, feeling productive and useful to others, affirmation of ability, and opportunities for social contact and personal development (Fossey & Harvey, 2010, p.308). The perspectives of individuals labeled with serious mental illness in these studies further spoke to the meaning associated with work, including creating a sense of wellness, improved relationships, and greater optimism, which were also seen as helpful in sustaining employment throughout the process of recovery.

       A study by Eklund, Hansson, and Bejerholm (2001) explored relationships between health-related variables and satisfaction with daily activities in 74 adults labeled with schizophrenia. This study found a significant positive correlation between satisfaction with employment status and global well-being, and it was found that employed individuals were more satisfied with their overall daily activities. Employed individuals in this study were also rated significantly better by interviewers on global quality of life, internal locus of control, and psychosocial functioning.


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     Another study explored the importance of work as compared to other types of activities with 105 individuals who were separated into three groups: those who were participating in competitive work or formal schooling, those who participated in structured activities other than work or school, and those who did not participate in any structured activities (Eklund, Hansson, & Ahlqvist, 2004). Results supported previous findings that individuals who were engaged in competitive work or school displayed better psychosocial functioning and reported significantly better satisfaction with daily activities than the other two groups. Of note, there was no significant difference in satisfaction with daily activities between the group of individuals who participated in structured activities besides work and the group who did not participate in any structured activities, indicating that there is a characteristic of work that contributes to a greater sense of well-being than participation in other types of activities.

     Gewurtz and Kirsh (2006) noted that “there was something about working that encouraged participants and transformed them from being a person with a mental illness to being a productive member of society” (p.6). This study explored the constructs of doing and becoming as related to participation in work for individuals labeled with serious mental illness and described participants’ experiences with work while illustrating the meaning that work brought to participants’ present lives and their futures. Through interviews, researchers found that doing work provided opportunities [for participants] to connect with others, improve their economic situations, and motivated them to manage their illness to ensure their ongoing ability to follow through with their commitments at work” (p.6). Participants also described how reflecting on their experiences of work led to self-discovery of individual skills and limitations and the ability to imagine a future for themselves as workers. On the other hand, “some of the stories recounted in the interviews suggested that the absence of doing [work] was a state filled with hopelessness in which a possible future was unimaginable” (p.10).


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A study that further explored the differences in perspectives and experiences between individuals labeled with serious mental illness who were employed and those who were not found that, like the employed participants in the previous study, the employed individuals in this study talked about being actively engaged in improving and maintaining their health, which indicates that they perceived themselves as in a state of health (Woodside, Scholl, & Allison-Hedges, 2006) . Contrary to this perspective, the individuals in this study who were not employed held the perspective that their symptoms of mental illness were a barrier to obtaining work and they questioned the effectiveness of their medical treatment, indicating that these individuals perceived themselves as not in a state of health (Woodside et al., 2006). It is important to note, however, that both groups of individuals, employed and unemployed, valued feeling comfortable with people at work, which supports the findings in other studies that work provides opportunities for social participation.

      From the perspectives of individuals labeled with serious mental illness, participation in work is associated with increased satisfaction with daily activities, improved sense of self, better health and well-being, and feelings of hope for the future. Participation in work is associated with better functioning and provides opportunities for meaningful social interactions, personal growth, and improved socioeconomic status, while lack of participation in work is associated with hopelessness, lower satisfaction with daily activities, and decreased overall health and well-being.

     Occupational therapists can support individuals labeled with mental illness throughout the recovery process, both in helping individuals to obtain jobs and to sustain employment. The participants in the study by Gewurtz and Kirsh (2006) brought to attention the importance of having someone who “believed in them, encouraged them, or expected that they could do more” (p.8) and participants in other studies have emphasized valuing strong collaborative relationships in which a sense of optimism, interest, and encouragement in pursuit of employment goals (Fossey & Harvey, 2010). Occupational therapy’s client-centered approach in empowering individuals to do the things they want to do affords a natural fit to the purpose of supporting individuals in believing in their capacity to work.


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   Occupational therapists can also support individuals in navigating employment support systems, developing strategies to manage the stress of job seeking, developing self-advocacy skills, and reflecting on the characteristics of various employment settings to ensure a good fit between the individual and the job. Participation in paid work is meaningful and contributes to recovery in a variety of ways, and through bolstering efforts to obtain and maintain employment, occupational therapists can support individuals labeled with serious mental illness in realizing their full potential as positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident


Eklund, M., Hansson, L., & Ahlqvist, C. (2004). The importance of work as compared to other forms of daily occupations for wellbeing and functioning among persons with long-term mental illness. Community Mental Health Journal, 40(5): 465-477.

Eklund, M., Hansson, L., & Bejerholm, U. (2001). Relationships between satisfaction with occupational factors and health-related variables in schizophrenia outpatients. Social Psychiatry and Psychiatric Epidemiology, 36, 79-85.

Fossey, E. M. & Harvey, C. A. (2010). Finding and sustaining employment: A qualitative meta-synthesis of mental health consumer views. Canadian Journal of Occupational Therapy, 77, 303-314. Doi: 10.2182/cjot.2010.77.5.6

Gewurtz, R. & Kirsh, B. (2006). How consumers of mental health services come to understand their potential for work: Doing and becoming revisited. The Canadian Journal of Occupational Therapy, 73(4 suppl.): 1-13.

Woodside, H., Scholl, L., & Allison-Hedges, J. (2006). Listening for recovery: The vocational success of people living with mental illness. The Canadian Journal of Occupational Therapy, 73(1): 36-43. Doi: 10.2182/cjot.05.0012.

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Occupational Therapy Can Support Treatments by Other Mental Health Providers

     Humans have evolved over time to automatically react, at a neurological level, to environmental sensory stimulation. Increased sensitivity and orientation to the light touch of a disease-spreading mosquito or the low growl of a hungry predator supported early humans in reacting quickly to fight or flee from environmental dangers, thus increasing chances of survival. This primitive sensory processing ability is still present in humans today, however, some people experience challenges in processing sensory stimulation that is associated with maladaptive coping strategies, mental health diagnoses, and decreased quality of life.  These sensory processing challenges often go undiagnosed and untreated, however occupational therapy provides a lens with which to treat individual sensory processing challenges and support recovery in mental health settings.

     Sensory defensiveness is a disorder of sensory processing in which the central nervous system has difficulty modulating sensory input, and is characterized by hypersensitivity, over-orienting, and aversion to everyday environmental stimulation (Kinnealey & Fuiek, 1999). Sensory defensiveness may result in the development of coping strategies that are time-consuming, emotionally exhausting, and/or socially unacceptable (Abernathy, 2010). sensory processing distress mental illnesss“Individuals with overresponsivity to sensation may withdraw from certain types of touch, cover their ears in response to everyday sounds, and/or avoid movement activities that are typically enjoyable or non-noxious to others. These individuals may also have limited diets due to sensitivity to the taste, smell or texture of certain foods. They may also get easily overwhelmed in certain environments, demonstrate strong emotional reactions to sensory stimuli, and engage in disruptive behaviors when demands become too great” (Reynolds & Lane, 2008, p.517).

     There is evidence that sensory defensiveness is co-morbid with various diagnoses of mental illness and results in decreased quality of life. Kinnealey & Fuiek (1999) reviewed a study that reported significantly higher levels of anxiety and depression in a group of people who were also found to display sensory-defensiveness. Abernathy (2010) reported on a study in which all participants were diagnosed with depression and either post-traumatic stress disorder, dissociative disorder, or borderline personality disorder; had a history of serious self-harming behavior, and were found to experience sensory defensiveness.  A study by Kinnealey, Koenig, & Smith (2011) found that sensory avoiding (a sensory processing pattern characterized by low thresholds for sensory stimulation combined with actively avoiding sensory input) was significantly correlated with decreased quality of life indicators, such as role emotional (participation), mental health, social functioning, general health, and increased bodily pain (Kinnealey, Koenig, & Smith, 2011). sensory defensiveness mental health occupational therapy

     Despite the negative effects on behavior and quality of life for individuals with sensory defensiveness, this sensory processing challenge is often undiagnosed and untreated in adults labeled with serious mental illness. Abernathy (2010) describes that sensory defensiveness is potentially misdiagnosed due to lack of knowledge surrounding its existence and the similarities between sensory defensiveness and various diagnoses of mental illness. “In her book, Heller (2003) described many case studies where individuals had been given a mental health diagnosis when the underlying problem was actually sensory defensiveness. The diagnoses that individuals were given varied and included anxiety disorder, borderline personality disorder, dissociative disorder and alcohol abuse (Abernathy, 2010, p.211). Regardless of the diagnosis, lack of treatment for sensory defensiveness can influence the effectiveness of other mental health treatment methods. cognitive behavior therapy mental health treatment “Sensory defensiveness is brainstem based and thus refers to reflexes and primitive, instinctive reactions that have their origin in bodily sensation, triggered by internal or external stimuli (Heller, 2003). For example, a person experiencing anxiety would not benefit fully from cognitive behavioural therapy if some of his or her anxiety is caused by sensory defensiveness, because his or her anxiety or panic does not have its origin with a negative thought but starts due to a primitive bodily reaction. If the sensory defensiveness is treated then the person will be able to address problems with anxiety that are cortex based and thus involve higher cognitive functioning” (Abernathy, 2010, p.211).

     Treatment of sensory defensiveness can be provided by occupational therapists, which can support the treatment of individuals labeled with mental illness by other providers in mental health settings. “Hale and Coy (1997) describe a sensory-based treatment intervention for sexually abused adolescents who were responding poorly to counseling alone…They describe improved success in treatment of these adolescents when there is collaboration between counselors who focus on social and emotional issues and occupational therapists who address underlying sensory processing problems” (Moore & Henry, 2002, p.46-7). Pfeiffer and Kinnealey (2003) conducted a study with 15 adults who displayed co-morbid anxiety and sensory defensiveness to determine the efficacy of treatment by occupational therapists.

occupational therapy mental health sensory processingThe treatment protocol included increasing client insight into sensory defensiveness, development of an individualized and regulated routine of exposure to sensory input, and engagement in daily physical activities of the individual’s choice. Following four weeks of treatment, levels of sensory defensiveness and anxiety in these individuals were significantly decreased. Despite the small sample sizes of these studies, the significance of these results supports continued efforts to identify individuals who experience sensory defensiveness and provide interventions to support their everyday functioning and success in recovery from mental illness.

                  Due to the abnormal distress that results from exposure to everyday sensory stimulation, individuals with sensory defensiveness develop learned patterns of avoidance to or display strong emotional and behavioral reactions in certain environments and activities. This negatively impacts one’s social connections and overall quality of life, and may act as a barrier to making progress in traditional mental health treatments. While the evidence is still emerging, results of treatment for sensory defensiveness by occupational therapists is positive and provides a rationale for mental health providers to engage in interprofessional collaboration with occupational therapists to effectively support the recovery of individuals labeled with mental illness.


Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident



Abernathy, H. (2010). The assessment and treatment of sensory defensiveness in adult mental health: a literature review. British Journal of Occupational Therapy, 73(5): 210-218. DOI:  10.4276/030802210X12734991664183

Kinnealey, M. & Fuiek, M. (1999). The relationship between sensory defensiveness, anxiety, depression, and perception of pain in adults. Occupational Therapy International, 6(3): 195-206.

Kinnealey, M., Koenig, K. P., & Smith, S. (2011). Relationships between sensory modulation and social supports and health-related quality of life. American Journal of Occupational Therapy, 65, 320–327. doi: 10.5014/ajot.2011.001370

Moore, K. M. & Henry, A. D. (2002) Treatment of adult psychiatric patients using the Wilbarger Protocol. Occupational Therapy in Mental Health, 18:1, 43-63, DOI:  10.1300/J004v18n01_03

Pfeiffer, B. & Kinnealey, M. (2003). Treatment of sensory defensiveness in adults. Occupational Therapy International. 10(3): 175-184.

Reynolds, S. & Lane, S. J. (2008). Diagnostic validity of sensory over-responsivity: A review of the literature and case reports. Journal of Autism and Developmental Disorders, 38(3): 516-529.



The Clubhouse: An Environment Where OTs Can Support Recovery

mental health sensory processing

       Occupational therapy’s distinct value in mental health lies in the emphasis on engagement in everyday activities, with the ultimate goal “to enable participation in personally and socially meaningful occupations that support health and well-being (Krupa, Fossey, Anthony, Brown, & Pitts, 2009, p.156). There are many settings within the community-based mental health service system through which occupational therapy has the potential support individuals labeled with serious mental illness (SMI), and a setting that stands out as an excellent fit is the Clubhouse.

          “Clubhouses are intentionally formed, non-clinical, integrated therapeutic working communities composed of adults and young adults diagnosed with SMI (members) and staff who are active in all Clubhouse activities. Clubhouse membership is open to anyone who has a history of mental illness. Membership is voluntary and without time limits. Being a member means that an individual is a critical part of the community and has both shared ownership and shared responsibility for the success of the Clubhouse” (McKay, Nugent, Johnsen, Eaton, & Lidz, 2018, p.29). A key feature of the clubhouse model is the work-ordered day, which refers to the expectation that staff and members work side-by-side, and the temporal flow of the clubhouse paralleling typical business activities and hours of operation of the working community where the clubhouse is located (Stoffel, 2011).

Painted Brain occupational therapy mental health     The clubhouse model implements several basic principles which emphasize individual strengths and potential, teamwork, the belief that work and work-mediated relationships support recovery, and empowerment through choice of activity (McKay et al., 2018, p.29). Clubhouses also provide support for gaining employment in the greater community through transitional employment, supported employment, or independent employment; participating in formal education; and connecting to resources in the community for health, finances, and housing. Also, 193 clubhouses responding to a survey regarding available activities reported offering some type of health promotion programming, including education on health, nutrition, and smoking sessions, and opportunities for exercise (McKay et al., 2018).

        Research has found many benefits to clubhouse participation. A study that compared clubhouse participants to participants in a program for assertive community treatment (PACT) found that “Clubhouse participants were employed more calendar days than PACT participants, worked significantly more hours, earned more during the study, and earned more per hour each week” (McKay et al., 2018, p.36). This same study also found that clubhouse participants reported greater quality of life related to social and financial aspects, and greater self-esteem and service satisfaction than PACT participants (McKay et al., 2018).

        Benefits of clubhouse participation are also found in the areas of physical health, rehospitalization rates, and social participation. A study on a 16-week structured exercise program implemented in a clubhouse called Genesis found that participants had significant improvements in aerobic capacity and perceived mental health, as well as positive changes in the domains of social and physical functioning, physical and emotional roles, vitality, and general health (Pelletier, Nguyen, Bradley, Johnsen, & McKay, 2005). A systematic review found results from 10 published studies that suggest clubhouse participants have lower rehospitalization rates, and the authors reasoned that evidence supported by at least 6 of the included studies suggest that Clubhouse participation may be beneficial in promoting social relationships by increasing social integration and supporting social competence (McKay et al., 2018).

mental health community
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The first clubhouse, established in New York City in 1948, was known as Fountain House, and offered its members supportive experiences in job training, arts and crafts, and recreational activities; occupational therapists were involved in Fountain House by leading workshops in fabricating small items (Stoffel, 2011). The clubhouse environment presents an ideal setting for occupational therapists to support the recovery of individuals labeled with serious mental illness due to the shared principles between the clubhouse model of psychosocial rehabilitation and the foundational theories of occupational therapy. Occupational therapy is founded on the principle that engagement in meaningful activities provides structure to an individual’s day and purpose to an individual’s life, resulting in improved physical and mental wellbeing, while the clubhouse model implements principles that emphasize structuring participation around the work-ordered day and supporting recovery through engagement in work and work-mediated relationships.


       The clubhouse model of psychosocial rehabilitation offers an environment in which individuals labeled with SMI can enter the community and be viewed as having individual strengths and potential to lead personally satisfying lives. Clubhouse participation has been found to be beneficial for individuals labeled with SMI through bolstering employment and educational opportunities, enhancing social participation, and connecting individuals to resources for health promotion. The clubhouse goals of helping individuals engage in meaningful work, supporting the pursuit of employment and formal education, and engaging in culturally relevant social and recreational activities are consistent with the occupational therapy domain of engagement in occupation to support overall health and well-being (Stoffel, 2011). Through innovation and client-centered practice occupational therapists can implement services in clubhouse settings to support the recovery of individuals labeled with serious mental illness and facilitate the realization that all people can be positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident



Krupa, T., Fossey, E., Anthony, W. A., Brown, C. & Pitts, D. B. (2009). Doing daily life: How occupational therapy can inform psychiatric rehabilitation practice. Psychiatric Rehabilitation Journal, 32(3): 155-161. Doi: 10.2975/32.3.2009.155.161

McKay, C., Nugent, K. L., Johnsen, M., Eaton, W. W., &  Lidz, C. W. (2018). A systematic review of evidence for the clubhouse model of psychosocial rehabilitation. Administrative Policy in Mental Health, 45: 28-47.

Pelletier, J. R., Nguyen, M., Bradley, K., Johnsen, M., & McKay, C. (2005). A study of a structured exercise program with members of an ICCD certified clubhouse: Program design, benefits, and implications for feasibility. Psychiatric Rehabilitation Journal, 29(2), 89-96.

Stoffel, V. C. (2011). Psychosocial Clubhouses. In C. Brown & V. C. Stoffel (Eds.), Occupational therapy in mental health: A vision for participation (Chapter 39, pp. 559–570). Philadelphia, PA: F. A. Davis Company.



Using Mobile Technology to Support Participation in Meaningful Activities

iPhone cell phone smartphone mental health meaningful activity

       The American Occupational Therapy Association (2010) states that “occupational therapy practitioners have long-standing expertise in providing occupational therapy services to clients that incorporate technology and environmental modification” (p.S44). The role of the occupational therapist in implementing technology-based interventions is to collaborate with the client and other professionals to determine an appropriate match between the client, the technology, and the environmental context in which the technology will be used, with the goal being “to promote, improve, or maintain the ability of people to engage in basic and instrumental activities of daily living: work, education, leisure, play, social participation, and sleep occupations that are meaningful and necessary” (AOTA, 2010, p.S45). Due to the accessibility of mobile technology, such as smartphones and tablets, these may be effective options for implementing technology-based interventions for adults labeled with serious mental illness (SMI). To determine if this is true, it is necessary to understand the health, participation, and engagement needs of adults labeled with SMI; the level and nature of access to technology held by this population; any possible barriers; and the efficacy of such interventions in supporting the specific health, participation, and engagement needs.

Health, Participation & Engagement Needs

        Individuals labeled with serious mental illness often experience difficulties in their daily lives that can be explained by challenges in cognitive abilities, such as planning, memory, attention, problem solving, and processing speed (Briand et al., 2018). Challenges with cognitive functioning have been described as one of the most debilitating features of SMI, and associated impacts on daily functioning include “decreased independence in self-care activities, difficulty maintaining relationships with family and friends, and decreased participation in community- and work-related tasks” (Gitlow et al., 2017, p.2). Traditional approaches to cognitive challenges generally include containment, medication administration, and contingency planning, which serve to limit risky behavior, but do not support underlying cognitive function or enhance participation and engagement in meaningful activities (Gillespie, Best, & O’Neill, 2017).

Level and Nature of Access

cell phone smartphone mental healthDue to the familiarity with mobile technology that many individuals labeled with SMI already display, such technology may be an effective tool to further support cognitive abilities, thereby positively influencing participation and engagement in meaningful activities. In 2010, global mobile phone ownership reached 91%, with 4.3 billion unique mobile subscribers identified (Donker et al., 2013). A study involving 457 people labeled with schizophrenia found that many individuals “have access to connected devices with results suggesting that the majority (61%) actually have access to two or three devices. Rates of access to mobile technology in this survey sample were similar to such rates in the general population, with 54% of respondents having access to a smartphone compared to 64% of Americans currently owning one (Gay, Torous, Joseph, Pandya, & Duckworth, 2016, p.6).

     Participants reported using their mobile technology to cope with their illness in a variety of ways, including by listening to music to block or manage auditory hallucinations; searching for information about mental health on the internet; using calendars for appointments or setting alarms; transportation needs; medication management; supporting others; developing relationships with others who have lived experience of schizophrenia; monitoring symptoms; and identifying coping strategies (Gay et al., 2016). Another study involving adults labeled with SMI found that “over 76.5% of the participants were basically satisfied with the devices they use and over half or more found them easy to use. This may mean these devices are integrated into the participants’ daily life routines and they would be useful as cognitive intervention strategies” (Gitlow et al., 2017, p.9).

Possible Barriers

mental illness occupational therapy meaningful activity      Studies that explored user experiences found both supports and barriers to incorporating mobile technology into therapeutic interventions. Seventy-five percent of participants in the survey by Gay et al. (2016) reported experiencing positive feelings in association with using their digital devices, including feeling happy, inspired, hopeful, peaceful, motivated, and empowered.

Participants did also report experiencing negative feelings 56% of the time, including feelings of being unable to stop, frustration, paranoia, worry, sadness, anger, mania, or envy; however, rates of negative feelings reported by respondents are similar to responses by individuals in the general population, with 36% and 15% of the general population reporting that their mobile phone use was associated feelings of frustration and anger, respectively (Gay et al., 2016).

Another systematic review of mobile phone use by individuals labeled with schizophrenia “found no evidence of adverse events such as increased paranoia, fear, or anger” (Gay et al., 2016, p.7), indicating that there are no additional risks beyond those posed to the general population. Other possible barriers to incorporating technology into therapeutic interventions include technical problems, issues of data security and privacy, cost, lack of knowledge about how technology can support participation, and fear that using technology to support function will signal that the user has a disability (Donker et al., 2013; Gitlow et al., 2017). Careful consideration of such barriers must be incorporated into the treatment planning process to minimize such risks while also ensuring successful outcomes.

Efficacy of Technology-Based Interventions

       Regarding clinical incorporation of mobile technology into therapeutic interventions, the most frequent use reported is “to support daily routines (personal hygiene, food preparation, and movement within and outside of the home), and in this regard, macro prompting devices (usually reminders to perform a task) are the most frequently used” (Gillespie et al., 2012, p.12). In the systematic review by Gillespie et al. (2012), good evidence was found that technology is effective in supporting cognitive abilities during task performance by providing cues that shift or redirect attention; with findings from 25 studies also showing moderate evidence for the efficacy of digital devices in supporting organization and planning abilities. Several case studies have also been completed that describe how mobile technology has been successful in supporting health, participation, and engagement in individuals labeled with SMI.

     Briand et al. (2018) described the case of Marguerite (pseudonym), a 79-year-old woman labeled with SMI, in which an occupational therapist worked with Marguerite to incorporate an iPad into her daily routine, supporting her ability to resume engagement in meaningful activities (ie. Painting, music); regain balance in her life (ie. sleep hygiene, leisure, cognitively stimulating games); and socialize in meaningful ways with her grandchildren. Another study by Hill, Belcher, Brigman, Renner & Stephens (2013) investigated the iPad™ as a tool to assist three young adults labeled with autism spectrum disorders or other SMI in structuring their daily routines, reducing anxiety, self-monitoring, and managing medication; implementing these strategies resulted in increased independence, job placement, and job retention for these individuals. While these small studies do not provide evidence of overall efficacy of mobile technology as a therapeutic intervention, they do illustrate the meaningful nature that this type of intervention may have for adults labeled with SMI.

mobile technology occupational therapy meaningful activityMobile technology is widely accessible to adults labeled with SMI, is already a part of the daily lives of many individuals, and provides features that are effective in addressing cognitive challenges that are barriers to participation in meaningful activities. Occupational therapists are uniquely qualified to successfully incorporate mobile technology into therapeutic interventions for adults labeled with SMI and can minimize risks due to foundational knowledge regarding technology and clinical-reasoning skills to carefully consider the interaction between physical, cognitive, environmental, and sociocultural factors in providing effective services (AOTA, 2010).

Factors associated with successful integration of technology into the rehabilitation process include a supportive clinician who can adjust to the individual’s needs, give meaning to the experience, enable learning despite cognitive challenges, support successful experiences to enhance self-efficacy, and assist the environment (including family) in supporting the individual’s use of the technology on an everyday basis (Briand et al., 2018). Furthermore, with a strong emphasis on client-centered therapy, occupational therapists can ensure that individuals labeled with SMI are involved as collaborative partners in the selection of specific mobile technology and applications that will build on well-established positive habits they already value, ensuring successful outcomes of increased independence, participation, and overall well-being (Gitlow et al., 2017).

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident





American Occupational Therapy Association. (2010). Specialized knowledge and skills in technology and environmental interventions for occupational therapy practice. American Journal of Occupational Therapy, 64(Suppl.), S44-S56. doi: 56:10.5014/ajot\.2010.64 S44-64S56

Briand, C., Sablier, J., Therrien, J. A., Charbonneau, K., Pelletier, J. P. & Weiss-Lambrou, R. (2018). Use of a mobile device in mental health rehabilitation: A clinical and comprehensive analysis of 11 cases, Neuropsychological Rehabilitation, 28:5, 832-863, doi:  10.1080/09602011.2015.1106954

Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M. R., & Christensen H. (2013). Smartphones for smarter delivery of mental health programs: A systematic review. Journal of Medical Internet Research, 15(11): e247. doi:10.2196/jmir.2791

Hill, D. A., Belcher, L., Brigman, H. E., Renner, S., & Stephens, B. (2013). The Apple iPadTM as an innovative employment support for young adults with autism spectrum disorder and other developmental disabilities. Journal of Applied Rehabilitation Counseling, 44(1): 28-37.

Gay, K., Torous, J., Joseph, A., Pandya, A., & Duckworth, K. (2016). Digital technology use among individuals with schizophrenia: Results of an online survey. JMIR Mental Health, 3(2): 1-9.

Gillespie, A., Best, C., & O’Neill, B. (2012). Cognitive function and assistive technology for cognition: A systematic review. Journal of the International Neuropsychological Society, 18, 1–19. doi:10.1017/S1355617711001548

Gitlow, L., Abdelaal, F., Etienne, A., Hensley, J., Krukowski, E., & Toner, M. (2017). Exploring the current usage and preferences for everyday technology among people with serious mental illnesses. Occupational Therapy in Mental Health, 33(1): 1-14.




Urban Gardening: A Community-Based Approach to Improving Mental Health

 urban gardening community based mental health       When seeking to creatively foster positive change in the mental health of individuals, a community-based approach may encourage participation of community members in a way that facilitates trust, alleviates discrimination, and promotes insight (Carney et al., 2012). Wakefield et al. (2007) highlight the role that community gardens play in the health and well-being of urban populations, while also emphasizing the interplay between the concepts of space, place, and occupational participation. In developing occupational therapy services in a community-based setting, literature such as this supports the development of client-centered programming that can impact the health and well-being of adults labeled with mental illness in a variety of ways.

       The urban population that served as the setting for the study by Wakefield et al. (2007) was an area of South-East Toronto, Canada; this area is characterized by high rates of poverty and ethnic diversity, and it encompasses Regent Park, Canada’s largest social housing complex. A strength of this study was the investigation of 15 different community gardens, which allowed for a robust inclusion of 68 participants (Wakefield et al., 2007). The researchers also described triangulation of data collection methods via observations, focus groups, and interviews, as well as the use of member checking techniques to increase the credibility of interpretations of participant experiences (Wakefield et al., 2007). Researchers described that they participated with the community gardeners by “planting seeds, carrying water, and shoveling dirt” (p.93), which most likely contributed to the development of trust between the researchers and the participants, and may have allowed for richer description of experiences and feelings regarding the community gardening experience, as well as more in-depth reflection by participants when they were asked to identify research questions and provide insight into the needs of the community.

community gardening mental health occupational therapyDespite the large sample size in this study, the study took place in only one area of one large city, and the number of participants was not great enough to allow for generalization of results. However, the qualitative data presented here does provide insight into the positive health implications of community gardens and illustrates the worry regarding pollution and permanence of such gardens that community members face.

    Important health benefits that were identified through participation in these community gardens were better access to food, improved nutrition, increased physical activity, and improved mental health. Attributes of the gardens that contributed to these health benefits through promotion of stress relief included the opportunity to interact with nature, the gardens conveying “a sense of lushness and abundance” (p.95), and the gardens offering “spaces of retreat within densely populated neighbourhoods” (Wakefield et al., 2007, p.95). This supports Hasselkus’s (2011) position that space and place contribute to health and well-being due to certain aspects of an environment promoting healing and recovery.

      Hasselkus (2011) also describes the ‘transactional unit’ which is comprised of the “dynamic relationship between people and the environments in which they carry out their everyday lives” (p.43) and which results in occupational performance. In the community gardens, the occupational performances of physical activity, social interaction, and growing fresh produce were a result of the interaction between the community members and the gardens. A crucial element in influencing the occupational choices of the community members was that the locations of the gardens were within the neighborhoods where the community members carried out their everyday lives.

FullSizeRender 2 copy         This view of the person-environment interaction also supports Persson & Erlandsson’s (2014) elaboration on the concept of ecology as the “interaction between the eco-system of the doer and the environmental ecosystem” (p.16) and the supposition that this interaction, when examined from a perspective of sustainability, has the potential to contribute to the well-being of the local environment, as well as the well-being of the greater ecosystem. The gardens did promote the well-being of the community members on a personal level, while also promoting well-being on community and environmental levels. Garden-based programming benefitted the community members on an individual level by creating an opportunity to come together to share tools, ideas, food, and culture, which contributed to decreased isolation, increased self-esteem, feelings of empowerment, and skill development (Wakefield et al., 2007).

     The garden-based programs benefitted the “community as a whole, by improving relationships among people, increasing community pride and in some cases by serving as an impetus for broader community improvement and mobilization” (Wakefield et al., 2007, p.97). The presence of the gardens contributed to community pride by enhancing the physical features of the neighborhoods, and working closely with the food that they were to eat, stimulated community members to think about such factors as pesticides, air pollution, and soil contamination.

           While the presence of community gardens provided an opportunity for health benefits on individual, local, and planetary levels, the meaningfulness of these gardens also stimulated concerns by the community members as to the sustainability of the garden plots. Wakefield et al. (2007) allude to the idea that social exclusion and marginalization are prevalent problems in neighborhoods of low socioeconomic status (SES), such as the neighborhoods where this study took place. The community members did express concerns about lack of awareness of the gardens and lack of political will to contribute resources to sustain the gardens, by the greater community and political leaders. These concerns were preempted by the recent initiation of re-development in Regent Park. This contributes to the study of occupational justice by highlighting the importance of the perspective of the community members in determining what is most meaningful and useful for themselves, the community, and the planet.

occupational therapy community gardening       Just as the participation of community members in the study by Wakefield et al. (2007) allowed researchers to understand what was meaningful about community gardens, the participation of community members in decisions about land development would contribute to fair allocation of resources to enable equitable distribution of rights and privileges in terms of occupational participation. However, the current state of Regent Park, with the initiation of re-development without input from those who reside in this housing complex, places the community members at risk for infringement on their freedom to participate in their valued occupation of gardening.

   This situation also contributes to an understanding of how occupational marginalization often “results from informal norms and expectations within a sociocultural infrastructure” (Durocher, 2014, p.422). The greater Toronto society may view residents of low SES neighborhoods to be involved in crime, or to not be concerned with such ideas as access to fresh produce, pollution, and community well-being, and these assumptions may lead political leaders to neglect to examine their expectations of the behavior of the inhabitants of such neighborhoods when making decisions about community development.

gardening mental health occupational therapy          The study of occupational science, which informs occupational therapy, has been developed through the amalgamation of perspectives from various disciplines on the study of factors affecting the participation and engagement of humans in everyday life. Due to the dynamic between the person and the environment, it is imperative that occupational science incorporates knowledge from disciplines that highlight this interaction to truly understand the meaning of occupational choices and the resulting occupational performances, as well as to appropriately promote participation and to address issues of occupational injustice and occupational marginalization. Wakefield et al. (2007), through a health promotion perspective, highlighted the importance of access to natural environments in promoting physical and mental health, contributing to social inclusion, inspiring appreciation for the natural environment, and in stimulating empowerment of community members to address larger social issues. This study also demonstrated the efficacy of a community-based approach in illuminating the client-centered perspective that is the hallmark of the occupational therapy profession.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident


Carney, P.A., Hamada, J.L., Rdesinski, R., Sprager, L., Nichols, K.R., Liu, B.Y. … Shannon, J.       (2012). Impact of a community gardening project on vegetable intake, food security and family relationships: A community-based participatory research study. Journal of Community Health, 37:874-881.

Durocher, E., Gibson, B.E., & Rappolt, S. (2014). Occupational justice: A conceptual review. Journal of Occupational Science, 21(4):418-430.

Hasselkus, B.R. (2011). “Chapter 3: Space and place: Sources of meaning in occupation” In Hasselkus, B.R. (Ed.) The meaning of everyday occupation (2nd ed.) (41-60). Thorofare: NJ: SLACK.

Persson, E. & Erlandsson, L.K. (2014). Ecopation: Connecting sustainability, glocalisation, and well-being. Journal of Occupational Science, 21(1):12-24.

Wakefield, S., Yeudall, F., Taron, C., Reynolds, J., & Skinner, A. (2007). Growing urban health: Community gardening in South-East Toronto. Health Promotion International, 22(2):92-101. doi:10.1093/heapro/dam001


Volition: Occupational Therapy’s Unique Understanding of the Human Motivation for Action

occupational therapy mental health
Occupational therapy
as a health profession is concerned with the ability of individuals to optimally perform activities that they want to do, need to do, or are expected to do by others. The Model of Human Occupation, a theoretical frame of reference that guides the practice of many occupational therapists, describes humans as possessing a “complex nervous system that gives them an intense and pervasive need to act…a body capable of action” and “an awareness of their potential for doing things” (Kielhofner, 2008, p.12). These human qualities combine to result in an innate desire for action, a motivation for occupational engagement, known as volition. Volition is comprised of three components: personal causation, the belief in one’s ability to act effectively; values, personal beliefs that give meaning to activities; and interests, individual preferences based on enjoyment of experiences (de las Heras, Llerena, & Kielhofner, 2003), and thus depends on how one views the self and to what situations one is attracted.

         Volition, however, does not exist as a fixed quality, but rather “is an ongoing process wherein one experiences occupations, interprets the experience through the process of reflection, anticipates further experiences based on this reflection and learning, and finally chooses activities and occupations based on the experience anticipated” (de las Heras et al., 2003, p.8). An individual with high volitional capacity views the self as being effective in his or her actions due to having experienced success; has the ability to reflect on his or her actions and find meaning; reflects hopefulness that future actions will also be successful; and exists in an environment that presents opportunities for making choices about future actions

      Schizophrenia is a mental illness characterized by positive symptoms or alterations in thoughts, beliefs, and sensory perceptions; and negative symptoms, which refers to diminished emotional expression and decreased motivation for self-initiated purposeful activities (APA, 2013). Emil Kraepelin, a German psychiatrist at the turn of the 20th century, described negative symptoms as avolitional syndrome, a ‘’weakening of those emotional activities which permanently form the mainsprings of volition,’’ and resulting in ‘‘loss of mastery over volition, of endeavor, and of ability for independent action,’’ (Buchanan, 2007, p.1013).

      Negative symptoms, more than positive symptoms, pose a greater risk for poor functional outcomes and long-term morbidity for individuals labeled with schizophrenia (Buchanan, 2007; Foussias, Mann, Zakzanis, van Reekum, & Remington, 2009). A study on the relationship between occupational engagement, symptoms of schizophrenia, and personal factors found that “those who had a low level of engagement exhibited little sense of coherence; external locus of control; low ratings of mastery; and more negative, positive, and general psychiatric symptoms” (Bejerholm & Eklund, 2007, p.26). The underlying reason for this may be related to difficulties in perceiving reality, which affects a person’s sense of self, and challenges in cognitive functioning that impact the ability to interpret and make sense of experiences, which disrupts the reflective stage that is integral to the volitional process (Bejerholm & Eklund, 2007).

schizophrenia mental illness

     Patricia Deegan (1988), an esteemed psychologist and person labeled with schizophrenia, describes her experience during the early days of her recovery:

For months I sat in a chair in my family’s living room, smoking cigarettes and waiting until it was 8:00 p.m. so I could go back to bed. At this time even the simplest of tasks were overwhelming. I remember being asked to come into the kitchen to help knead some bread dough. I got up, went into the kitchen, and looked at the dough for what seemed an eternity. Then I walked back to my chair and wept. The task seemed overwhelming to me. Later I learned the reason for this: when one lives without hope, (when one has given up) the willingness to “do” is paralyzed as well (p.13).

       Deegan’s experience with schizophrenia began in young adulthood and disrupted her life story in a way that she perceived as a “catastrophic shattering of [her] world, hopes, and dreams” (Deegan, 1988, p.12). Deegan (1988) describes having recently applied to college and having made plans for becoming a teacher when her diagnosis was presented as an “incurable malady” that would cause her to “be ‘sick’ or ‘disabled’ for the rest of [her life]” (p.12). This diagnosis of mental illness changed Deegan’s sense of personal causation as her belief that she could be effective was devastated by being told she had a chronic disabling condition. When the individual loses belief in her ability to be effective, and experiences disruptions in the experience of doing, the cyclical nature of the volitional process is interrupted and the resulting inertia “paralyzes the will to do and to accomplish because there is no hope” (Deegan, 1988, p.13).

reflection hope activity engagement mental health

        It is then the charge of the occupational therapist to rekindle a sense of hope, such that the individual can transition from inertia to involvement in daily life. Remarkably, “involvement in daily life has been shown to reduce negative symptoms in persons with schizophrenia” (Bejerholm & Eklund, 2007, p.22), while no other traditional treatments have been effective in addressing these symptoms. Occupational therapists, as health professionals who hold expertise in the complexities of engagement in everyday living and the underlying motivation to act, are an integral component of mental health services. Occupational therapists can support the capacity of individuals labeled with mental illness in performing activities that they want, need, and are expected to do, such that they can realize their full potential as positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident


American Psychiatric Association (APA) (2013). Diagnostic and statistical manual of mental disorders, 5th edition. Arlington, VA: American Psychiatric Association. Retrieved from

Bejerholm, U. & Eklund. M. (2007). Occupational engagement in persons with schizophrenia: Relationships to self-related variables, psychopathology, and quality of life. American Journal of Occupational Therapy, 61, 21-32.

Buchanan, R. W. (2007). Persistent negative symptoms in schizophrenia: An overview. Schizophrenia Bulletin. 33(4): 1013-1022. doi:10.1093/schbul/sbl057

Deegan, P. (1988). Recovery: the lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4): 11-19.

de las Heras, C. G., Llerena, V., & Kielhofner, G. (2003). A user’s manual for remotivation process: Progressive intervention for individuals with severe volitional challenges. Chicago, IL: Model of Human Occupation Clearinghouse.

Foussias, G., Mann, S., Zakzanis, K. K., van Reekum, R., & Remington, G. (2009). Motivational deficits as the central link to functioning in schizophrenia: A pilot study. Schizophrenia Research, 115(2009): 333-337. doi:10.1016/j.schres.2009.09.020

Kielhofner, G. (2008). Model of human occupation: Theory and application, 4th edition. Baltimore, MD: Lippincott Williams & Wilkins.

Companionship with Dogs: An Opportunity to Support Resilience in Adults Labeled with Mental Illness

IMGP0644         The status of a person’s mental health is related to how the person copes with and responds to stressful situations, and occupational therapy is an integral component in the development of coping strategies that enhance abilities to effectively manage stress. Research on resilience to stress shows that social support through quality relationships is integral to maintaining optimal physical and mental health, such that “positive social support of high quality can enhance resilience to stress, help protect against developing trauma-related psychopathology, decrease the functional consequences of trauma-induced disorders, such as post-traumatic stress disorder (PTSD), and reduce medical morbidity and mortality” (Ozbay, Johnson, Dimoulas, Morgan III, Charnay, & Southwick, 2007, p.35). For example, a study involving Vietnam veterans found that individuals with high levels of social support were 180% less likely to develop PTSD than individuals with low levels of social support, and another study discovered that patients with acute and chronic cardiac illness displayed decreased depression when they utilized active coping mechanisms, which were preceded by high levels of social support (Ozbay et al., 2007). Research on the perspectives of adults labeled with serious mental illness has also revealed that participation in valued social roles provides individuals with a sense of meaning and purpose and is associated with increased self-esteem and decreased symptoms and hospitalizations (Deegan, 2005).

oxytocin stress relief petting a dog         On a neurophysiological level, the neurotransmitter oxytocin has been investigated as a component in the regulation of social attachment and promotion of positive social interactions, and findings conclude that oxytocin is associated with reductions in anxiety and reduced secretion of stress-related hormones (Ozbay et al., 2007). Therefore, increased levels of oxytocin may contribute to increased positive social interactions and subsequently increased development of quality social support systems.

     Occupational therapy interventions that promote the development of quality social support systems may be more effective when incorporating components that facilitate increased secretion of oxytocin. One way to facilitate this may be through animal-assisted interventions, specifically interventions that incorporate dogs. Physical interaction with dogs has been found to result in increased release of oxytocin in both humans and dogs (Beetz, Uvnas-Moberg, Julius, & Kotrschal, 2012). Not only can petting a dog promote the development of the ideal internal environment necessary to prime individuals for social interaction, but that same dog can establish an external environment in which other people are drawn to interact socially with the person who is next to the dog.

social interaction dogs animal assisted therapyStudies on the benefits of human-canine interaction have found that the presence of a service dog was associated with increased friendly social attention, smiles, and conversation from others for persons who use wheelchairs (Beetz et al., 2012), dogs provided a safe topic of conversation among dog owners who frequented a local park in the UK (Robins, Sanders, & Cahill, 1991), and in a study in Western Australia, 83.3% of owners who walked their dogs reported talking with other pet owners during those walks (Wood, Giles-Corti, & Bulsara, 2005). This presents an opportunity for occupational therapy interventions for adults labeled with mental illness, specifically when goals include boosting resilience to stress through the development of increased social participation and establishment of social support networks. However, this area of intervention has only been minimally studied and rarely implemented.

      In a study involving adults labeled with mental illness who live in a Canadian community, pet-owners demonstrated higher frequency of social interaction with neighbors than non-pet owners; however, of the participants in this study only 18.6% were pet owners, which is a considerable amount lower than the 53% of the general Canadian population who own a pet (Zimolag & Krupa, 2009). When looking at the numbers of dog-owners specifically, 15% of pet owners in the study by Zimolag and Krupa (2009) lived with one dog; again, this is significantly less than the number of Americans who live with a dog, which is calculated to be 36.5% of the general population (AVMA, 2018).  Of the non-pet owners in this study, 63.2% reported a desire to live with a pet due to hopes of experiencing companionship; and the three most frequently reported motivations for living with a pet in the pet-owner group were companionship, someone to love, and stress relief (Zimolag & Krupa, 2009). There appears to be a wealth of opportunity to facilitate increased resilience to stress in adults labeled with mental illness by establishing increased social support networks through supporting companionship with dogs.

petting a dog mental health occupational therapy Painted Brain Los Angeles   Occupational therapy facilitates resilience in the population of adults labeled with mental illness through the development of coping strategies to effectively manage stress, stress is managed more effectively when individuals have higher secretion of oxytocin and increased access to positive social support systems, and companionship with dogs is associated with increased secretion of oxytocin and positive social interaction with others. A substantial proportion of adults labeled with mental illness who live in the community may desire the companionship of a dog, and supporting companionship of dogs through occupational therapy interventions presents an opportunity to increase the frequency and quality of social interactions experienced by adults labeled with mental illness, such that they can establish increased positive social support networks, increased resilience to stressful situations, and ultimately increased overall well-being.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident



American Veterinary Medical Association (AVMA). (2018). U.S. Pet ownership statistics [2012 U.S. Pet Ownership & Demographics Sourcebook]. Retrieved from

Beetz, A., Uvnas-Moberg, K., Julius, H., & Kotrschal, K. (2012). Psychosocial and psychophysiological effects of human-animal interactions: The possible role of oxytocin.  Frontiers in Psychology, 3(234): 1-15.

Deegan, P. (2005). The importance of personal medicine: A qualitative study of resilience in people with psychiatric disabilities. Scandinavian Journal of Public Health, 33(Suppl): 29-35. doi: 10.1080/14034950510033345

Ozbay, F., Johnson, D.C., Dimoulas, E., Morgan III, C.A., Charnay, D., & Southwick, S. (2007). Social support and resilience to stress: From neurobiology to clinical practice. Psychiatry, 35-40.

Robins, D.M., Sanders, C.R., & Cahill, S.E. (1991). Dogs and their people: Pet-facilitated interaction in a public setting. Journal of Contemporary Ethnography, 20(1):3-25.

Wood, L., Giles-Corti, B., & Bulsara, M. (2005). The pet connection: Pets as a conduit for social capital. Social Science & Medicine, 61, 1159-1173.

Zimolag, U., & Krupa, T. (2009). Pet ownership as a meaningful community occupation for people with serious mental illness. American Journal of Occupational Therapy, 63, 126-137.

Collaborative Documentation: An Innovative Approach to Client Empowerment

Painted Brain occupational therapy mental healthOccupational therapy was founded on two beliefs: that “man, through the use of his hands as they are energized by mind and will, can influence the state of his own health” (p.88) and that illness and unhappiness occur when a person has lost the agency to act on his own behalf (Reilly, 1962). In any setting, occupational therapists focus their services on facilitating optimal functioning of their clientele, such that their minds and wills are energized to use their hands effectively. In a mental health setting, this often involves the implementation of innovative approaches to engage and empower the client throughout the recovery process. One innovative approach that may be integral to the engagement and empowerment of clientele in mental health settings, is collaborative documentation.

    Collaborative, or concurrent, documentation (CD) may support the increased implementation of shared decision making while also increasing client empowerment and engagement, improving treatment outcomes, and decreasing emotional burnout on providers. Collaborative documentation changes the focus of assessment, planning, and evaluation documentation by allowing for the client and provider to work together to complete all documentation during face-to-face sessions (Stanhope, Ingoglia, Schmelter, & Marcus, 2013). This type of collaboration throughout the intervention process ensures that the client’s personal goals and values are upheld, that the client and provider leave each session with the same understanding, and that the client is empowered to challenge provider’s assumptions about adherence to treatment. Collaborative documentation is associated with a stronger therapeutic alliance, which is associated with increased client engagement; improved outcomes; and enhanced efficiency and quality of work-life for providers (Maniss & Pruit, 2018).

occupational therapy recovery client engagement
Illustration by Larry Rozner

Collaborative documentation facilitates increased involvement of the client in making decisions for her/his own care because the client is expected to engage as a partner in generating progress notes and intervention plans during each session. Thus, “the role of client changes from one of mental patient who is written about to a person who is becoming part of the action and part of the solution. This type of empowerment process can drive reductions in the client’s internalization of mental illness stigma” (Sheehan & Lewicki, 2016, p.310) and increase the client’s engagement in the therapeutic process.


One study found “that person-centered planning and collaborative documentation were associated with greater engagement in services (a decrease in no-shows) and higher rates of medication adherence” (Stanhope et al., 2013, p.79), and there is “evidence to suggest that a strong working alliance is related to an increased understanding of the meaning of the interventions utilized during direct service provision. As such, intersession processing and generalization of skills could be promoted through collaborative reflection and synthesis of the session content through a practice like collaborative documentation” (Maniss & Pruit, 2018, p.10-11). Collaborative documentation practices are also associated with improved outcomes and increased medication adherence. In an 11-month study involving clients with schizophrenia and bipolar disorders, medication adherence was significantly more improved at facilities that implemented collaborative documentation (Stanhope et al., 2013).

       Despite the fact that clinicians spend nearly one third of their time on paperwork and administrative tasks, view documentation as the least desirable part of their job, and report higher levels of emotional exhaustion when spending large amounts of time on paperwork (Sheehan & Lewicki, 2016), some providers have resisted implementation of collaborative documentation due to fears that viewing their medical records will be emotionally dysregulating for clients. In a quasi-experimental study initiated in 2010, 20,000 clients were invited to read their physicians notes; of the participants who completed surveys regarding reading of the notes, approximately 99% supported continuation of the practice and reported benefits, such as “increased understanding of their health concerns and improved adherence to treatment plans including medications, as well as a greater sense of involvement and control in their health decisions. Notably, most participants were not worried, confused, or offended by physicians’ comments in the medical records” (Maniss & Pruit, 2018, p.4). In another study by the National Council, of more than 15,000 mental health clients with CD experiences, 82% reported that the practice was “helpful” or “very helpful” when implemented for progress notes, and more than 70% of respondents reported that they would feel favorably toward using CD in the future” (Sheehan & Lewicki, 2016, p.308).

balance productivity self-care leisure sleep

     With evidence that clients perceive collaborative documentation as positive, providers can implement this innovative practice to benefit their clients, while also benefiting themselves.  Implementation of CD in practice can save providers valuable time and energy, which can be better utilized during direct contact with clients or implementing self-care strategies to support their own mental health. At a large mental health center serving approximately 10,000 individuals in Illinois, providers who implemented CD decreased their documentation time from an average of 11 minutes per client to 3 minutes per client (Maniss & Pruit, 2018); this translates to saving an average of more than five hours of documentation time per week. Furthermore, clinicians who practice CD have described shifting the emphasis in their notes from labeling to describing, which results in more person-centered and non-judgmental language that supports treatment and client’s personal goals (Maniss & Pruit, 2018).

   The process of collaborative documentation conveys several messages of empowerment, including “(a) that clients are capable of planning and describing their own treatment; (b) that clients’ words are important enough to use in written documents; (c) that clients have the right and responsibility to review records and correct clinicians; and (d) that clients can cognitively and emotionally manage the information” (Sheehan & Lewicki, 2016, p.310). Collaborative documentation practices are associated with increased client engagement in the therapeutic process, improved outcomes, and increased efficiency and well-being for providers. With the shift in mental health services to a recovery approach, which upholds the client’s values and perspective, an innovative practice such as collaborative documentation is an integral component of today’s mental health services. Occupational therapy’s belief in the fundamental need and ability to be an agent in one’s own health aligns with the approach of collaborative documentation to empower the client to take charge of her own mental health by becoming an equal partner with the clinician throughout all aspects of the process, such that the client can realize her full potential as a positively contributing member of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident



Maniss, S. & Pruit, A. G. (2018). Collaborative documentation for behavioral healthcare providers: An emerging practice. Journal of Human Services: Training, Research, & Practice, 3(1): 1-23.

Reilly, M. (1962). The 1961 Eleanor Clarke Slagle lecture: Occupational therapy can be one of the great ideas of 20th century medicine. American Journal of Occupational Therapy, 16(1): 87-105.

Sheehan, L. & Lewicki, T. (2016). Collaborative documentation in mental health: Applications to rehabilitation counseling. Rehabilitation, Research, Policy, & Education, 30(3): 305-320.

Stanhope, V., Ingoglia, C., Schmelter, B., & Marcus, S. C. (2013). Impact of person-centered planning and collaborative documentation on treatment adherence. Psychiatric Services, 64(1): 76-79.



The Assessment of Motor and Process Skills: A Person-Centered Approach to Mental Health Services

mental health services occupational therapy AMPS

     An important focus of occupational therapy in a community-based mental health setting is supporting individuals in the performance of activities of daily living. Engagement in activities of daily living, which includes grooming and hygiene, meal preparation, and home management tasks, contributes directly to increased independence and community participation. To implement effective interventions that contribute to measurable improvement in activity performance and accurate recommendations for community-based living, the evaluation process must precisely determine an individual’s strengths and areas of need as related to activities that are relevant to the person’s daily life. However, it is important to accomplish this with a person-centered and collaborative approach that empowers the individual and contributes to decreased stigma of mental illness.

     In traditional mental health services, evaluations are conducted with a focus on deficits and assess discrete underlying components of performance separately from global performance in meaningful tasks (Pan & Fisher, 1994). This method of evaluation requires the therapist to infer the relationship between underlying functional ability and actual task performance, which is subjective and possibly inaccurate. In a study that explored the experiences of individuals in recovery from mental illness, participants reported perceptions that there was a lack of depth in assessments and that they desired a more comprehensive evaluation process (Donal et al., 2018). Participants in this study also expressed frustration at their lack of autonomy and power over their own care, while also recognizing that “trust was fostered when practitioners personally invested in them and expressed a respectful curiosity about their lives” (Donal et al., 2018, p.6).

activities of daily living
The Assessment of Motor and Process Skills (AMPS) is an innovative occupational therapy-specific observational assessment of performance in activities of daily living. The AMPS was developed based on the assertions that occupational therapy services must center on understanding the client’s perspective, that evaluations and interventions must be based on the activities that an individual performs in daily life, and that the occupational therapy process is most effective when beginning from a top-down approach (Fisher & Jones, 2010).

      The AMPS evaluation begins with an interview so that the occupational therapist can develop a keen understanding of the client’s life and the meaningful activities that the person engages in on a daily basis. The client chooses two activities to perform that are relevant to his or her daily life; the occupational therapist then observes the client performing the tasks in the client’s natural environment and rates the quality of performance based on the observable motor and process skills that comprise each task. “Motor skills relate to how the person moves him/herself, tools, and materials during the task, such as walking, bending, lifting, and manipulating items. Process skills relate to applying knowledge, organizational ability, and adaptation when problems occur, such as logically sequencing steps of the task, heeding the goal, and organizing the workspace” (Ayres & John, 2015, p.472).

     The opportunity for the client to make choices during the evaluation process, while also considering the impact of the environment, contribute to the innovative nature of the AMPS and allow occupational therapy to stand out in the field of functional assessment. “The AMPS use of tasks that are  familiar and ecologically relevant to the client avoids the limitations inherent in the use of highly standardized, often contrived tests in which all persons perform the same tasks whether the tasks are related to the person’s interests and values or the tasks have any apparent relationship to the ability to  live independently” (Pan & Fisher, 1994, p.780).

mental illness occupational therapy assessment

       A study on the use of the AMPS with individuals with schizophrenia found that clients were generally accepting of this type of assessment (Ayres & John, 2015). Initially, the study included 78 participants; one person was not able to tolerate the assessment process, and 7 others later declined. The researchers reported initial concern that “the intense scrutiny and note taking by the observing occupational therapist during the task performance would be off-putting for people, particularly those with anxiety or paranoia; however, the vast majority reported that this was not so. [The researchers] found that the client-centered nature of task selection has contributed to a willingness to participate” (Ayres & John, 2015, p.475).

     The ability of occupational therapists to conduct person-centered observational assessments of relevant tasks in natural environments using a tool such as the AMPS contributes to the discipline’s uniqueness and value in community-based mental health services, and directly supports individuals with mental illness in realizing their full potential as independent and positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident


**The AMPS is now available at Painted Brain **



Ayres, H. & John, A. P. (2015) The Assessment of Motor and Process Skills as a measure of ADL ability in schizophrenia. Scandinavian Journal of Occupational Therapy, 22(6): 470-477, DOI: 10.3109/11038128.2015.1061050

Donal, O., Sheridan, A., Kelly, A., Doyle, R., Madigan, K., Lawlor, E., & Clarke, M. (2018). ‘Recovery’ in the real world: Service user experiences of mental health service use and recommendations for change 20 years on from a first episode psychosis. Administration and Policy in Mental Health and Mental Health Services Research

Fisher, A. G. & Jones, K. B. (2010). Assessment of motor and process skills, Volume 1: Development standardization, and administration manual, 7th edition, revised. Fort Collins, CO: Three Star Press, Inc.

Pan, A. & Fisher, A. G. (1994). The Assessment of Motor & Process Skills of persons with psychiatric disorders. American Journal of Occupational Therapy, 48(9): 775-780.


Sensory Modulation: An Occupational Therapy Perspective on Behavior

While psychiatric diagnoses are often determined by analyzing a person’s behavior or emotional regulation abilities, occupational therapy provides a keen understanding of the underlying neurophysiological functioning that precedes behavioral and emotional responses, and thus has the opportunity to contribute an effective lens to intervene and support an individual’s mental health. When viewing behavior as a response to sensory stimulation in the environment, it is critical to understand all the components of processing sensory stimulation. One component of sensory processing that can lead to maladaptive behavioral responses when compromised, is sensory modulation.

Modulation can be thought of as regulating or adjusting a certain level; toning down; or adapting to circumstances. At a neurological level, modulation takes place in the brain and spinal cord, and “reflects the balancing of excitatory and inhibitory inputs and adapting to environmental changes” (Bundy, Lane, & Murray, 2002, p.103). Sensory modulation encompasses the central nervous system’s ability to regulate and organize sensory input such that an organism can produce a behavioral response that matches the demands of the environment (Lipskaya-Velikovskya, Bar-Sharlitaa, & Bart, 2015; Wallis, Sutton, & Bassett, 2017).

mental health sensory processing
Any human in any environment is exposed to a variety of stimulation (i.e. sights, sounds, smells, textures, movements). If all of this stimulation were registered in the nervous system at the same intensity, the system would be overloaded with information, rendering the person unable to pay attention, make decisions, and behave appropriately. Modulation of sensory information is reflected in the nervous system becoming either habituated or sensitized to sensory stimuli.  “Habituation occurs when the central nervous system recognizes stimuli as familiar and therefore no longer responds to them. Sensitization is the process in which the central nervous system recognizes stimuli as harmful or important and therefore heightens the response” (Pfeiffer & Kinnealey, 2003, p. 176).

Thus, the ability to modulate sensory input is fundamental to our ability as humans to participate in meaningful activities because modulation allows us to filter irrelevant sensory input, attend to what is important, and maintain an optimal level of arousal (Bundy et al., 2002). For example, modulation allows a person to attend to a conversation with a friend in a crowded restaurant, focus on taking an exam in a room with other students, and refrain from panicking when hearing a fire engine siren.

Some individuals, however, experience difficulties with sensory modulation. “Sensory modulation disorder (SMD) interferes with modulation across one or multiple sensory systems and is manifested in reduced participation in daily life occupations. Subtypes of SMD include sensory over-responsivity (SOR), in which non-painful sensations are perceived as abnormally aversive, irritating or painful; and sensory under-responsivity (SUR), which manifests as decreased and/or delayed responses to stimuli” (Lipskaya-Velikovskya et al., 2015, p.131). When modulation of sensory information is ineffective, individuals experience either an uncontrolled increase in arousal due to attending to an overwhelming amount of sensory input or an uncontrolled lack of arousal due to not attending to enough sensory input. A key factor here is increased “autonomic arousal, which is known to influence affect and emotion, and can lead to aggressive behaviour” due to the “fight-or-flight” response that is facilitated by arousal of the autonomic system (Sutton, Wilson, Van Kessel, & Vanderpyl, 2013, p.500).

sensory processing and mental health
Photo by Tom Fox Photos

Research shows that some forms of mental illness are associated with increased difficulties in sensory processing that may be linked to challenges with modulation. A scoping review found evidence that people with bipolar disorder and schizophrenia often experience increased difficulties in filtering auditory information and difficulties processing visual information, leading to challenges in attention in sensory-rich environments, as well as difficulties with noticing important information (Bailliard & Whigham, 2017). This review also found that individuals with schizophrenia and bipolar disorder tend to score significantly higher on the sensation avoiding quadrant of the Adolescent/Adult Sensory Profile, while individuals with major affective disorders are twice as likely to experience atypical sensory sensitivity and sensation avoiding, indicating low thresholds across multiple sensory systems and putting the individual at risk for becoming overwhelmed in multisensory environments (Bailliard & Whigham, 2017).sensory processing seclusion and restraintHistorically, interventions to address behavioral responses like aggression, in individuals with mental illness, have been punitive and inhumane, such as the ‘seclusion and restraint’ methods employed in inpatient psychiatric facilities. A pilot study of a sensory-based intervention in an inpatient psychiatric facility found that “deliberate use of sensory inputs can promote a recursive regulation of arousal by accessing evolutionarily advanced neural pathways that promote adaptive, social behaviours” (Sutton et al., 2013, p.507). Participants in this study, which included both patients who utilized the sensory-based arousal regulation strategies as well as staff, reported that the sensory-based intervention facilitated a calm state of arousal, enhanced interpersonal interaction, and supported self-management of emotional states (Sutton et al., 2013, p.507).  This is because certain types of sensory input, such as movement of the limbs and deep pressure on the skin, facilitate a sense of safety by supporting awareness of the body and enhancing modulation of the other senses (Sutton et al., 2013).


By focusing the intervention on sensory processing, rather than the behavior, it is possible to develop a greater understanding of the person behind the aggression and to intervene with empathy and expertise, rather than with a punitive reaction. Occupational therapists, as experts in sensory processing, are integral to the development of sensory-based interventions for adults with mental health challenges in a variety of settings and can support both providers and individuals seeking mental health services in developing increased insight into the underlying neurophysiological functioning that contributes to participation in meaningful activities.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident


Bundy, A. C., Lane, S. J., & Murray, E. A. (2002). Sensory integration: Theory and practice, 2nd ed. Philadelphia, PA: F. A. Davis Company.

Bailliard, A. L., & Whigham, S. C. (2017). Centennial Topics—Linking neuroscience, function, and intervention: A scoping review of sensory processing and mental illness. American Journal of Occupational Therapy, 71, 7105100040.

Lipskaya-Velikovskya, L., Bar-Sharlitaa, T., & Bart, O. (2015). Sensory modulation and daily-life participation in people with schizophrenia. Comprehensive Psychiatry, 58, 130-137.

Pfeiffer, B. & Kinnealey, M. (2003). Treatment of sensory defensiveness in adults. Occupational Therapy International, 10(3): 175-184.

Sutton, D., Wilson, M., Van Kessel, K., & Vanderpyl, J. (2013). Optimizing arousal to manage aggression: A pilot study of sensory modulation. International Journal of Mental Health Nursing, 22, 500–511.

Wallis, K., Sutton, D., & Bassett, S. (2017): Sensory modulation for people with anxiety in a community mental health setting, Occupational Therapy in Mental Health, DOI:10.1080/0164212X.2017.1363681